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Acetaminophen
4%
3/68
Aspirin
3%
2/68
Iron
6%
4/68
Lead
74%
50/68
Nortriptyline
12%
8/68
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This child has iron toxicity as evidenced by the clinical picture of abdominal pain, bloody emesis, a metabolic acidosis, and radiopaque tablets on radiography. Iron overdose presents with vomiting, diarrhea, gastrointestinal hemorrhage, fever, and lethargy. Symptoms can begin within 30-60 minutes following ingestion and escalate to circulatory shock after 48 hours. The pathophysiology of iron overdose is a consequence of free iron's toxicity to vasculature, release of serotonin and histamine, injury to mitochondria, lipid peroxidation, and the uncoupling of oxidative phosphorylation. The treatment is to immediately stabilize the patient and administer deferoxamine. After initial management, endoscopy is performed at a later time. Incorrect Answers: Answer 1: Acetaminophen toxicity presents with hepatic failure. Patients may present without any symptoms or they could present with nausea, vomiting, and signs of liver failure. Liver enzyme elevation is often into the 1,000's or 10,000's. N-acetylcysteine is the recommended treatment. Answer 2: Aspirin toxicity classically presents with a mixed respiratory alkalosis and metabolic acidosis. Activated charcoal for gastric decontamination and sodium bicarbonate for urine alkalinization are used in cases of poisoning with aspirin. Unique presenting symptoms include tinnitus. Answer 4: Lead toxicity causes neurologic signs such as parasthesias and muscle weakness, metallic taste, and hemolysis. Chronic symptoms can include poor performance in school, irritability, and constipation. Oral succimer can be given as a chelating agent in mild or moderate lead poisoning. Answer 5: Nortriptyline, a tricyclic antidepressant, can cause anticholinergic effects as well as deadly arrhythmias. Patients may present with confusion, dry/hot skin, urinary retention, and constipation. The best test for TCA overdose is an ECG which will demonstrate QRS widening. Treatment includes sodium bicarbonate administration. Bullet Summary: Iron overdose presents with nausea, vomiting, abdominal pain, and radiopaque pills in the GI tract.
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